Factors associated with long-term functional outcomes, psychological sequelae and quality of life in persons after primary brain tumour

Cancer survivorship: understanding the patients' journey and perspectives on post-treatment needs

BACKGROUND

Cancer treatments have many adverse effects on patient's health leading to poor cardiorespiratory capacity, muscular- degeneration, fatigue, loss of strength and physical function, altered body-composition, compromised immune-function, peripheral neuropathy, and reduced quality of life (QOL). Exercise programs can significantly increase functional capacity when tailored to individual needs, thus improving health. Exercise interventions in cancer rehabilitation, when supported by appropriate nutrition can be effective in attaining a healthy weight and body-composition. The successful rehabilitation program should also include psycho-social education aimed to reduce anxiety and improve motivation.

METHODS

The current study aimed to collect information on the post-treatment needs of cancer patients including barriers and expectations facing them, their caregivers and their families through consultation in focus group interviews. Cancer survivors living in the Republic of Ireland were recruited from the University Hospital Galway, community-based cancer centres, cancer support groups and social media platforms to participate in the study and attend a focus group interview. The focus group discussions were designed to obtain information on the collective views of cancer survivors on relevant topics selected. The topics were developed in consultation with a patient and public involvement (PPI) group supporting the study. The topics list was circulated to all participants prior to the focus group. The interviews were audio recorded and transcribed verbatim. Focus group transcripts were analysed subjected to a thematic framework analysis using NVivo.

RESULTS

Thirty-six participants took part in 9 focus groups. Our analysis uncovered two main themes. The first theme 'cast adrift with no direction' was grouped into three sub-themes: everything revolves around treatment; panic and fear; and what exercise should I be doing? The second theme 'everybody is different' was clustered into two sub-themes: side effects get in the way; and personalised exercise program.

CONCLUSION

The study highlighted the lack of information and support needed by patients living with and beyond cancer. The study also highlighted the need for a personalised exercise programme designed to target the individual patient symptoms that would be ideal for the mitigation of long term symptoms and in improving QOL.

Neural and Onconeural Autoantibodies and Blood-Brain Barrier Disruption Markers in Patients Undergoing Radiotherapy for High-Grade Primary Brain Tumour

Radiotherapy (RT) plays a key role in brain tumours but can negatively impact functional outcomes and quality of life. The aim of this study was to analyse anti-neural and onconeural autoantibodies and markers of blood-brain barrier (BBB) disruption in patients with primary brain cancer undergoing RT.

MATERIALS AND METHODS

A prospective study was conducted on 45 patients with a brain tumour scheduled for intensity-modulated radiotherapy. Assessments were performed at baseline, post-RT, and at three months. We measured serum levels of BBB disruption biomarkers and anti-neural, onconeural, and organ-specific antibodies.

RESULTS

Antibodies against nucleosome antigens and neuronal surface antigens were detected in 85% and 3% of cases, respectively; anti-neural and onconeural antibodies were observed in 47% and 5.8%. In 44% patients, ≥2 antibody types were detected. No significant changes in BBB biomarkers were observed.

CONCLUSION

The findings of this study show that a humoral immune response is common in patients undergoing RT for brain cancer. This response appears to be non-organ specific but rather directed against nucleosome antigens, but onconeural antibodies were uncommon, suggesting a low risk of a neurological paraneoplastic syndrome. Our data suggested that radiotherapy may not affect BBB integrity, but larger studies are needed to better characterise the pathophysiological effects of RT.

Prevalence of unmet supportive care needs reported by individuals ever diagnosed with cancer in Australia: a systematic review to support service prioritisation

PURPOSE

Improved health outcomes for individuals ever diagnosed with cancer require comprehensive, coordinated care that addresses their supportive care needs. Implementing interventions to address these is confounded by a lack of evidence on population needs and a large pool of potential interventions. This systematic review estimates the point prevalence of different supportive care needs stratified by the tool used to measure needs and cancer type in Australia.

METHODS

We searched MEDLINE, Embase, and Scopus from 2010 to April 2023 to identify relevant studies published on the prevalence of supportive care needs in Australia.

RESULTS

We identified 35 studies that met the inclusion criteria. The highest prevalent unmet need across all cancers was 'fear of cancer spreading' (20.7%) from the Supportive Care Needs Survey Short-Form 34 (SCNS-SF34), ranging from 9.4% for individuals ever diagnosed with haematological cancer to 36.3% for individuals ever diagnosed with gynaecological cancer, and 'concerns about cancer coming back' (17.9%) from the Cancer Survivors' Unmet Needs (CaSUN), ranging from 9.7% for individuals ever diagnosed with prostate cancer to 37.8% for individuals ever diagnosed with breast cancer. Two studies assessed needs in Aboriginal and Torres Strait Islander populations, reporting the highest needs for financial worries (21.1%).

CONCLUSIONS

Point prevalence estimates presented here, combined with estimates of the costs and effects of potential interventions, can be used within economic evaluations to inform evidence-based local service provision to address the supportive care needs of individuals ever diagnosed with cancer.

IMPLICATIONS FOR CANCER SURVIVORS

Local health services can use local evidence to prioritise the implementation of interventions targeted at unmet needs.

Identification of health-related quality of life profiles among long-term survivors of primary central nervous system tumors

PURPOSE

We aimed to identify health-related quality of life (HRQOL) latent classes among primary central nervous system tumor (PCNST) long-term survivors (LTS) and to evaluate differences between classes in survivor sociodemographic characteristics, clinical characteristics, and symptoms to guide  the development of survivorship care programs tailored to unique class needs.

METHODS

Data from 298 PCNST LTS reporting HRQOL on the EQ-5D-3L were analyzed using latent profile analysis. Correlations and independent group t-tests were performed to identify differences between identified HRQOL classes by sociodemographic, clinical characteristics, and symptoms.

RESULTS

Sample mean age was 48 years, 54% were male, 82% Caucasian, 56% employed, 60% had a high-grade glioma, and 52% had a KPS ≥ 90. Two HRQOL classes, good (61%) and poor (39%), were identified. The good HRQOL class reported no problems with self-care and few problems with mobility or usual activities. Thirty-eight percent reported anxiety and depression and 21% pain. Over 94% of the poor HRQOL class had at least moderate problems with mobility and usual activities, and over 50% had pain, self-care issues, anxiety, and depression. Older age (φ = 0.21), unemployment (φ = 0.30), spine tumors (φ = 0.18), active treatment (φ = 0.20), tumor recurrence (φ = 0.28), and poorer KPS scores (φ = 0.61) were associated with membership in the poor HRQOL class.

CONCLUSIONS

In the poor PCNST LTS HRQOL class, an overwhelming majority faced significant physical challenges, and the good HRQOL class experienced mood-related disturbance but limited physical challenges. These HRQOL profiles can be used to guide survivorship programs and tailored interventions.

Experiences of work for people living with a grade 2/3 oligodendroglioma: a qualitative analysis within the Ways Ahead study

OBJECTIVES

This study aimed to explore the work experiences of people living with an oligodendroglioma.

DESIGN

This was a descriptive qualitative study. One-time semi-structured interviews exploring supportive care needs were conducted; work was discussed at various points throughout each interview. An inductive thematic analysis was undertaken.

SETTING

Participants were recruited across the UK through four National Health Service hospitals and the Brain Tumour Charity research involvement networks.

PARTICIPANTS

19 people with grade 2 or 3 oligodendroglioma (mean age 52 years; male n=11). At diagnosis, 16 participants were working, 2 studying and 1 retired. At the interview (mean time since diagnosis 9.6 years; range 1-18 years), seven participants were working, eight retired (four on medical grounds) and four unable to work due to illness.

RESULTS

Seven themes were constructed: (1) physical and cognitive limitations; (2) work ability and productivity; (3) work accommodations; (4) changing roles; (5) attitudes of clients and coworkers; (6) feelings and ambitions; and (7) financial implications. Fatigue, seizures and cognitive deficits influenced work ability. A stressful work environment could exacerbate symptoms. Changes in job roles and work environment were often required. Employer and coworker support were integral to positive experiences. Work changes could result in financial stress and strain.

CONCLUSIONS

This study has highlighted, for the first time, influences on work experiences in this understudied population. These findings have implications for clinicians and employers, when considering the importance of work in rehabilitation for people with oligodendrogliomas, and the individually assessed adjustments required to accommodate them, should employment be desired.

Conformal Radiation Therapy for Ependymoma at Age ≤3 Years: A 25-Year Experience

PURPOSE

Adjuvant radiation therapy (RT) affects survival after surgery for young children (age <3 years) diagnosed with intracranial ependymoma. Conformal photon RT promised to spare normal tissue and was introduced more than 25 years ago to improve outcomes for these vulnerable patients. Long-term results for those first treated with conformal methods provide valuable information and serve as a comparison against newer methods.

METHODS AND MATERIALS

Between 1997 and 2018, 101 patients <3.1-years-old were treated with conformal and intensity modulated photon therapy after definitive surgery for intracranial ependymoma. The median age at RT was 2.1 years and the time from diagnosis to the start of RT was 10 weeks. The extent of resection was gross-total in 82%, and 38% underwent more than 1 attempt at resection. The total prescribed dose was 54 to 59.4 Gy at 1.8 Gy per fraction.

RESULTS

The 10-year event-free and overall survivals were 58.5% ± 5.0% and 72.6% ± 4.5%, respectively, with a median follow-up of 18.4 years (range, 4.2-23.3 years). Tumor progression occurred in 34 patients with a median time of 1.6 years. Death occurred in 34 patients from ependymoma (n = 24), secondary malignancy (n = 6), necrosis (n = 2), shunt failure (n = 1), and anaphylactic reaction (n = 1). Twenty-three patients developed a secondary tumor including 6 cases of fatal high-grade glioma. Of the surviving cohort and those ≥18 years old, 98% obtained a high school diploma, 64% had a current driver's license, 89% were students or employed full or part time, 32% were living independently, and 70% received higher education or training.

CONCLUSIONS

Long-term results of children treated using photon conformal RT after surgery demonstrate that adjuvant RT resulted in long-term disease control and functional independence. These results point to the need for new treatment strategies to improve tumor control and provide investigators hope that newer RT methods will further reduce complications.

Developing behavioural activation for people with acquired brain injury: a qualitative interpretive description study of barriers and facilitators to activity engagement

BACKGROUND

Acquired brain injuries (ABI) from stroke, head injury, or resected brain tumours are associated with poor emotional wellbeing and heightened risk of mood disorder. Common sequalae of ABI, such as poor attention and memory, can create barriers to the efficacy of cognitively demanding mood interventions, such as Cognitive Behavioural Therapy (CBT). Behavioural Activation (BA), where individuals plan and engage in reinforcing activities, is a promising alternative due to lower cognitive demands. However, BA was initially developed in clinical populations without ABI where the primary barriers to activity engagement were low mood and anxious avoidance. Additionally, BA can incorporate a range of techniques (e.g., mood monitoring, activity scheduling, targeting avoidance, contingency management) and psychoeducational topics (e.g., mindfulness, managing uncertainty; social/communication skills). Exploring barriers and facilitators to adopting specific BA components in ABI is an important aim.

METHODS

Semi-structured interviews were conducted with purposively selected ABI survivors (N = 16) with both low and high depressive symptoms, and family members (N = 7). Questions focused on routine and enjoyable activities, and feedback on 10 different BA techniques and associated psychoeducational topics. Transcripts were analysed using an interpretive description framework. Analysis was informed by field notes, reflexivity diaries, and peer debriefing.

RESULTS

The final constructed framework, Creating Sustainable Engagement, comprises a two-tier hierarchy. Higher-level themes concerned core perspectives of BA, regardless of BA component discussed. This included identifying optimal time windows for different BA components (Right Tool at the Right Time), that BA components should, at least initially, not be burdensome or fatiguing (Perceived Effort), that emotional readiness to confront activity-mood relationships should be addressed (Emotional Impact), and that planned BA activities be consistent with individual values (Relation to Values). Lower-level themes concerned specific BA components: Of these, activity scheduling, procedures targeting avoidance, managing uncertainty and social/communication skills were generally well-received, while mood monitoring, contingency management, and mindfulness had mixed feedback.

CONCLUSIONS

BA is a widely scalable intervention that can be adapted for ABI. This study provides a novel framework on implementing a range of BA components in ABI and adds to the limited evidence on which components may be particularly suitable.

Health-related quality of life in adults with low-grade gliomas: a systematic review

PURPOSE

Low-grade glioma (LGG) patients may face health-related quality-of-life (HRQoL) impairments, due to the tumour, treatment and associated side-effects and prospects of progression. We systematically identified quantitative studies assessing HRQoL in adult LGG patients, for: aspects of HRQoL impacted; comparisons with non-cancer controls (NCC) and other groups; temporal trends; and factors associated with HRQoL.

METHODS

MEDLINE, CINAHL, Embase, PubMed, and PsycINFO were systematically searched from inception to 14th September 2021. Following independent screening of titles and abstracts and full-texts, population and study characteristics, and HRQoL findings were abstracted from eligible papers, and quality appraised. Narrative synthesis was conducted.

RESULTS

Twenty-nine papers reporting 22 studies (cross-sectional, n = 13; longitudinal, n = 9) were identified. Papers were largely good quality, though many excluded patients with cognitive and communication impairments. Comparators included high-grade gliomas (HGG) (n = 7); NCCs (n = 6) and other patient groups (n = 3). Nineteen factors, primarily treatment (n = 8), were examined for association with HRQoL. There was substantial heterogeneity in HRQoL instruments used, factors and aspects of HRQoL assessed and measurement timepoints. HRQoL, primarily cognitive functioning and fatigue, in adult LGG patients is poor, and worse than in NCCs, though better than in HGG patients. Over time, HRQoL remained low, but stable. Epilepsy/seizure burden was most consistently associated with worse HRQoL.

CONCLUSION

LGG patients experience wide-ranging HRQoL impairments. HRQoL in those with cognitive and communication impairments requires further investigation. These findings may help clinicians recognise current supportive care needs and inform types and timings of support needed, as well as inform future interventions.

Social relationships and relational pain in brain tumor patients and their partners

Partners play an important role in both the general well-being and the care needs of patients. The dynamic between brain tumor treatment and patients' families is a complex bidirectional relationship. Cancer diagnosis and treatments which leave patients compromised impact the nature and quality of their relationships, and these in turn impact the ability of their partners to care for them. This paper will review the nature of the impact of diagnosis and treatment on relationships and how couples and families respond to the disruption of cancer treatments. The impact of how emotional and social pain effect their relationships and their ability to engage in care will be addressed.

Factors associated with health-related quality of life in patients with glioma: impact of symptoms and implications for rehabilitation

OBJECTIVE

The factors associated with health-related quality of life in patients with glioma remain unclear; particularly, the impact of symptoms on quality of life has not been studied comprehensively. This study aims to document the quality of life of patients with glioma and clarify the impact of symptoms.

METHODS

In this cross-sectional study, participants were recruited from patients at The University of Tokyo Hospital and from patients who were registered at the Japan Brain Tumor Alliance. We included adult patients with World Health Organization grade II-IV glioma and excluded those with disturbances of consciousness or aphasia. We used the European Organization for Research and Treatment of Cancer QLQ-C30 and BN20 to evaluate quality of life and the symptoms. Multiple regression analyses were performed to investigate the impact of symptoms on European Organization for Research and Treatment of Cancer global health status and QLQ-C30 social functioning. In addition, we performed univariate subgroup analyses classified by World Health Organization grade and history of chemotherapy.

RESULTS

This study included 76 patients. Seven symptoms occurred in more than 50% of the patients: fatigue, future uncertainty, drowsiness, communication deficit, financial difficulties, motor dysfunction and weakness of legs. Multiple regression analyses showed that insomnia affected their global health status, and appetite loss, financial difficulties and motor dysfunction were significantly related to their social functioning. In subgroup analysis, the number of symptom subscales that were significantly related to global health status and social functioning was larger in World Health Organization grade II patients compared with grade III/IV patients.

CONCLUSIONS

In addition to neurological deficits, symptoms were associated with poor quality of life in patients with glioma. This study provided the basis on further investigation of usefulness of symptom evaluation on quality of life improvement.

The role of poor motor coordination in predicting adults' health related quality of life

BACKGROUND

Developmental coordination disorder (DCD) and its functional restrictions may persist into adulthood. Nevertheless, the knowledge about DCD in adulthood and its association with health related quality of life (HRQOL) is limited.

AIMS

To explore how individuals with suspected DCD experience DCD impacts as children and as adults and how these experiences predict their HRQOL.

METHODS

Participants were 200 healthy individuals aged 20-64 (mean 32.66 ± 11.51): 18 with suspected DCD and 182 with normal motor performance (according to the Adult Developmental Coordination Disorder/Dyspraxia, ADC, Checklist cut-off score). Participants completed a sociodemographic/health questionnaire, the ADC and the WHOQOL-BREF which measures physical, psychological, social and environmental HRQOL.

RESULTS

The group with suspected DCD had significantly lower HRQOL (except for the physical domain). In the general sample, current feelings about the individual's performance predicted all HRQOL domains. Among the study group, HRQOL was predicted by current perception of performance and difficulties experienced as a child.

CONCLUSIONS AND IMPLICATIONS

The negative effects of DCD during childhood and adulthood may reduce adults' HRQOL, mainly in the psycho-social and environmental domains. The detailed profile provided by the ADC with its functional context may assist in evaluating DCD in adults and in tailoring intervention for improving HRQOL.

Ways Ahead: developing a supported self-management programme for people living with low- and intermediate-grade gliomas - a protocol for a multi-method study

INTRODUCTION

Living with and beyond a diagnosis of a low- and intermediate-grade glioma (LIGG) can adversely impact many aspects of people's lives and their quality of life (QoL). In people with chronic conditions, self-management can improve QoL. This is especially true if people are supported to self-manage. Supported self-management programmes have been developed for several cancers, but the unique challenges experienced by LIGG survivors mean these programmes may not be readily transferable to this group. The Ways Ahead study aims to address this gap by exploring the needs of LIGG survivors to develop a prototype for a supported self-management programme tailored to this group.

METHODS AND ANALYSIS

Ways Ahead will follow three sequential phases, underpinned by a systematic review of self-management interventions in cancer. In phase 1, qualitative methods will be used to explore and understand the issues faced by LIGG survivors, as well as the barriers and facilitators to self-management. Three sets of interviews will be conducted with LIGG survivors, their informal carers and professionals. Thematic analysis will be conducted with reference to the Theoretical Domains Framework and Normalisation Process Theory. Phase 2 will involve co-production workshops to generate ideas for the design of a supported self-management programme. Workshop outputs will be translated into a design specification for a prototype programme. Finally, phase 3 will involve a health economic assessment to examine the feasibility and benefits of incorporating the proposed programme into the current survivorship care pathway. This prototype will then be ready for testing in a subsequent trial.

ETHICS AND DISSEMINATION

The study has been reviewed and approved by an National Health Service Research Ethics Committee (REC ref: 20/WA/0118). The findings will be disseminated through peer-reviewed journals, conference presentations, broadcast media, the study website, The Brain Tumour Charity and stakeholder engagement activities.

Comparison of Upper Extremity Function in Women With and Women Without a History of Breast Cancer

BACKGROUND

Breast cancer treatments often result in upper extremity functional limitations in both the short and long term. Current evidence makes comparisons against a baseline or contralateral limb, but does not consider changes in function associated with aging.

OBJECTIVE

The objective of this study was to compare upper extremity function between women treated for breast cancer more than 12 months in the past and women without cancer.

DESIGN

This was an observational cross-sectional study.

METHODS

Women who were diagnosed with breast cancer and had a mean post-surgical treatment time of 51 months (range = 12-336 months) were compared with women who did not have breast cancer (CTRL group). Self-reported upper extremity function using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and shoulder range of motion, strength, and muscular endurance were measured. Participants were divided into 3 groups: breast cancer involving the nondominant limb (BC-ND), breast cancer involving the dominant limb (BC-DOM), and CTRL.

RESULTS

A total of 59 women in the CTRL group, 23 women in the BC-ND group, and 28 women in the BC-DOM group completed measures. Mean DASH scores in women with breast cancer were higher than those of women in the CTRL group, regardless of the limb on which cancer occurred (Cohen d = 1.13; 95% CI = 2.20 to 16.21) Range of motion for the BC-ND group was significantly less for flexion (Cohen d = 1.19, 95% CI = -13.08 to -0.11) and external rotation (Cohen d = 1.11, 95% CI = -18.62 to -1.98) compared with the CTRL group. Strength in the BC-ND group was 23% to 25% lower in the CTRL group for external (Cohen's d = 0.89, 95% CI = 0.09 to 0.12) and internal rotation (Cohen d = 0.92, 95% CI = 0.10 to 0.13). Endurance was not significantly different in the 3 groups.

LIMITATIONS

Some participants had rehabilitation, which may have skewed results. The range of post-surgical treatment times was broad, making it difficult to determine when function returned. Muscular endurance measures demonstrated a ceiling effect and large variance, limiting the ability to distinguish differences among participants. These results may not be generalizable to the subset of women who were treated with lumpectomy, sentinel node biopsy, or chest wall radiation alone or who underwent a contralateral prophylactic mastectomy.

CONCLUSION

In the long term, women with breast cancer have lower self-reported shoulder function than women without breast cancer. Motion and strength are lower among women who have experienced cancer on the nondominant limb.

The importance of social relationships for brain tumor patients' quality of life: A case for the inclusion of the concept of disclosure in psycho-oncological care

Purpose: Interpersonal factors are of major importance for cancer patients' physical and mental health. Brain tumor patients rank amongst those cancer patients with the highest psychosocial burden. Changes in language, cognition, and personality pose specific risk factors for impeding interpersonal functioning in this patient group. Despite this, role and relevance of social support including both supportive (e.g., emotional support) and detrimental interactions causing distress (e.g., critical remarks) are not well understood. Aims of this study were thus (1) to investigate the association of social support and patients' Health Related Quality of Life (HRQoL) and (2) to assess whether this relationship is mediated by the patients' disclosure behavior.Methods: Seventy-four ambulatory brain tumor patients (mean age 54 years; 58% women) completed the following self-report questionnaires: Illness-specific Social Support Scale (SSUK) for assessment of positive support and detrimental interactions, the Disclosure of Trauma Questionnaire (DTQ) for assessment of patients' disclosure behavior, and the Short-Form Health Survey (SF-8) for assessment of QoL.Findings: Detrimental social interactions were significantly related to patients' mental and physical well-being while positive support was not. Our results support a model in which patients perceiving detrimental social interactions show more difficulties in talking about illness-specific contents in a functional manner. This, in turn, was associated with a lower physical and mental HRQoL.Conclusions: This was the first study in which the close associations of detrimental social interactions, brain tumor patients' dysfunctional disclosure behavior and patients' mental as well as physical well-being were empiricially validated. Thus, dysfunctional disclosure behavior might pose a relevant therapeutic target when offering psycho-oncological support for brain tumor patients and their families.

Attainment of Functional and Social Independence in Adult Survivors of Pediatric CNS Tumors: A Report From the St Jude Lifetime Cohort Study

Purpose Beyond survival, achieving independence is a primary goal for adult survivors of pediatric CNS tumors. However, the prevalence of and risk factors for failure to achieve independence, assessed with multiple concurrent indicators, have not been examined. Patients and Methods Functional and social independence was assessed in 306 survivors (astrocytoma [n = 130], medulloblastoma [n = 77], ependymoma [n = 36], and other [n = 63]; median current age, 25.3 years [range, 18.9 to 53.1 years]; time since diagnosis, 16.8 years [range, 10.6 to 41.8 years]). Six observed indicators were used to identify latent classes of independence, which included employment, living independently, assistance with personal care, assistance with routine needs, obtaining a driver's license, and marital status. Physical performance impairments were defined as scores < 10th percentile on measures of aerobic capacity, strength, flexibility, balance, mobility, and adaptive function. Multinomial logistic regression estimated odds ratios (ORs) and 95% CIs were calculated for associations of disease/treatment exposures and impairments in physical performance with nonindependence. Results Three classes of independence were identified as independent (40%), moderately independent (34%), and nonindependent (26%). In multivariable models, craniospinal irradiation (OR, 4.20; 95% CI, 1.69 to 10.44) and younger age at diagnosis (OR, 1.24; 95% CI, 1.14 to 1.35) were associated with risk of nonindependence versus independence. Beyond impaired IQ, limitations in aerobic capacity (OR, 5.47; 95% CI, 1.78 to 16.76), flexibility (OR, 3.66; 95% CI, 1.11 to 12.03), and adaptive physical function (OR, 11.54; 95% CI, 3.57 to 37.27) were associated with nonindependence versus independence. Nonindependent survivors reported reduced physical but not mental health-related quality of life compared with independent survivors. Conclusion Sixty percent of survivors of pediatric CNS tumors do not achieve complete independence as adults. Reduction in intensity of primary therapies and interventions that target physical performance and adaptive deficits may help survivors to achieve greater independence.

Psychiatric co-morbidity, distress, and use of psycho-social services in adult glioma patients-a prospective study

BACKGROUND

Distress impacts the daily life of glioma patients. This study explored its course over time and the usage of psychosocial care.

METHODS

A consecutive sample of glioma patients completed the Hospital Anxiety and Depression Scale to assess distress levels at admission to the hospital (t1), before discharge (t2), after 3 months (t3), and after 6 months (t4). They were interviewed with the Structured Clinical Interview for DSM-IV to ascertain psychiatric disorders at t2. Psycho-oncological care in the hospital was determined with the Hospital Information System, and the use of outpatient treatment was evaluated with the Health Care Usage Questionnaire at t4. We compared the percentages of elevated distress, psychiatric co-morbidity, and care usage between men and women.

RESULTS

During the study period, 37 patients were enrolled. Nineteen percent of the patients were diagnosed with a psychiatric disorder. The percentages of patients with elevated distress were 56, 59, 39, and 40% at t1, t2, t3, and t4, respectively. Participants who did not survive the 6 months presented with higher levels of distress. In the hospital, 14% of those with elevated distress were visited by a psycho-oncologist. In the outpatient setting, 43% of those with elevated distress visited a neuro-psychiatrist, and 14% went to a psychotherapist. There was no evidence for an effect of gender on psychiatric co-morbidity, distress, or care use.

CONCLUSIONS

A significant proportion of glioma patients report elevated distress during the hospital stay and thereafter. Only a fraction of them receive mental health care.

Health-Related Quality of Life and Cancer-Related Symptoms During Interdisciplinary Outpatient Rehabilitation for Malignant Brain Tumor

OBJECTIVE

The aim of the study was to determine the relationships between functional outcomes, clinical symptoms, and health-related quality of life among patients with malignant brain tumors receiving interdisciplinary outpatient rehabilitation.

DESIGN

A prospective study of 49 adults with malignant brain tumors participating in outpatient therapies was performed. Outcome measures included the Functional Assessment of Cancer Therapy-Brain (FACT-Br) for health-related quality of life and the Patient-Reported Outcome Measures Instrument Survey (PROMIS) Depression and Pain Behavior scales measured at admission, discharge, 1 and 3 mos after discharge. Day Rehabilitation Outcome Scale (DayROS), a functional measure, was measured at admission and discharge.

RESULTS

The FACT-Br scores, PROMIS pain, and PROMIS depression scores did not significantly change. There were many negative associations seen between FACT-Br and PROMIS depression (all P < .0001) and less associations with PROMIS pain. There was a positive correlation between Day Rehabilitation Outcome Scale and FACT-Br (P = .0058) and a negative association with PROMIS pain (P = .028), but not with PROMIS depression. There were no correlations between Day Rehabilitation Outcome Scale gains and change in PROMIS depression, FACT-Br total, or PROMIS pain.

CONCLUSIONS

Health-related quality of life, pain, and depression did not worsen. Patients who reported less depression and pain had better reported health-related quality of life. Level of function was also associated with HRQOL and pain, but not depression.

Qualitative research on the Belgian Cancer Rehabilitation Evaluation System (CARES): An evaluation of the content validity and feasibility

RATIONALE, AIMS, AND OBJECTIVES

The systematic assessment of cancer patients well-being and care needs is internationally recommended to optimize comprehensive cancer care. The Cancer Rehabilitation Evaluation System (CARES) is a psychometrically robust quality of life and needs assessment tool of US origin, developed in the early 1990s. This article describes Belgian patients' view on the content validity and feasibility of the CARES for use in current cancer care.

METHODS

Participants were cancer patients recruited through media. Data were gathered in 4 focus groups (n = 26). The focus group discussions were facilitated with key questions. A moderator and an observer conducted and followed up the discussion. The audio file was transcribed verbatim and afterwards analyzed thematically.

RESULTS

Participants experience concerns and needs in a wide range of life domains such as physical, emotional, cognitive, social, relational, sexual, financial, and work-related and in the interaction with care professionals. According to participants, the items of the CARES are all relevant to capture the possible life disruption that cancer patients and survivors experience. One important theme is missing in the CARES, namely, the well-being of loved ones. The completion time of the CARES was judged to be feasible, and according to participants, only a few items need a reformulation.

CONCLUSIONS

In general, the results of this study support the content validity and feasibility of the CARES. However, little adjustments in formulation and a few extra items are needed. The instrument can be used to obtain a comprehensive assessment of a cancer patients' overall well-being and care needs to take dedicated action in care.

Prospective analysis of neuropsychological deficits following resection of benign skull base meningiomas

OBJECTIVE Resection of skull base tumors is challenging. The introduction of alternative treatment options, such as radiotherapy, has sparked discussion regarding outcome in terms of quality of life and neuropsychological deficits. So far, however, no prospective data are available on this topic. METHODS A total of 58 patients with skull base meningiomas who underwent surgery for the first time were enrolled in this prospective single-center trial. The average age of the patients was 56.4 ± 12.5 years. Seventy-nine percent of the tumors were located within the anterior skull base. Neurological examinations and neuropsychological testing were performed at 3 time points: 1 day prior to surgery (T1), 3-5 months after surgery (T2), and 9-12 months after surgery (T3). The average follow-up duration was 13.8 months. Neuropsychological assessment consisted of quality of life, depression and anxiety, verbal learning and memory, cognitive speed, attention and concentration, figural memory, and visual-motor speed. RESULTS Following surgery, 23% of patients showed transient neurological deficits and 12% showed permanent new neurological deficits with varying grades of manifestation. Postoperative quality of life, however, remained stable and was slightly improved at follow-up examinations at T3 (60.6 ± 21.5 vs 63.6 ± 24.1 points), and there was no observed effect on anxiety and depression. Long-term verbal memory, working memory, and executive functioning were slightly affected within the first months following surgery and appeared to be the most vulnerable to impairment by the tumor or the resection but were stable or improved in the majority of patients at long-term follow-up examinations after 1 year. CONCLUSIONS This report describes the first prospective study of neuropsychological outcomes following resection of skull base meningiomas and, as such, contributes to a better understanding of postoperative impairment in these patients. Despite deterioration in a minority of patients on subscales of the measures used, the majority demonstrated stable or improved outcome at follow-up assessments.

Correlation between hormone receptor status and depressive symptoms in patients with metastatic breast cancer

Individual differences in depressive symptoms correlate with morbidity and outcomes in breast cancer patients. We evaluated the effect of hormone receptor (HR) status on depressive symptoms in 176 women with metastatic breast cancer at diagnosis. To assess depression, the women completed Self-Rating Depression Scale (SDS) questionnaires at baseline examination (T1), after 4 chemotherapy cycles (T2) and after 6 months (T3). At baseline examination, 45/176 (25.6%) patients were found to be at high or medium risk for depression (SDS score ≥0.6). Among these, depression was both prevalent in HR-positive patients and in HR-negative patients (64.4% versus 51.4%, P = 0.001). In multivariate model, HR positivity and higher depression risk were associated with poorer overall survival (25.0 months versus 32.0 months, P < 0.05). Patients at high/medium risk of depression were treated with the antidepressant agent fluoxetine (N = 23) or no drug (N = 22). SDS scores in patients treated with fluoxetine were lower after 4 chemotherapy cycles and after 6 months than in the control group (mean scores: T2, 0.61 versus 0.67, P = 0.001; T3, 0.56 versus 0.65, P < 0.001). No difference on SDS scores was found between patients with positive or negative HR status during fluoxetine treatment. These findings suggest hormone receptor status is associated with depressive symptoms in patients with metastatic breast cancer. Fluoxetine relieves depressive symptoms in these patients, regardless of hormone receptor status.

Health-Related Quality of Life in Brain Tumor Patients Treated with Surgery: Preliminary Result of a Single Institution

Background

Alongside the extent of removal and patients’ survival in the management of brain tumors, health-related quality of life (HRQOL) has become an important consideration. The purpose of this study is to evaluate the change of HRQOL in brain tumor patients before and after surgery and to assess the associated factors that contribute to the change of HRQOL.

Methods

A total of 258 patients who underwent surgical treatment were enrolled in this study. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire 30 (EORTC QLQ-C30) and the 20-item EORTC QLQ-Brain Neoplasm (QLQ-BN20) were used to assess HRQOL. Patients were asked to fill out the questionnaires before and 3-6 months after surgery.

Results

Global QOL (p<0.001) and emotional function (p<0.018) were significantly improved after surgery. Physical function (p=0.015) was significantly aggravated. Among the symptoms, headache, pain and nausea and vomiting were significantly decreased (p<0.01, p=0.041, p<0.001, respectively), while dyspnea, communication deficit and weakness of the legs were increased (p=0.005, p=0.040, and p=0.014, respectively). Preoperative neurologic deficit (p=0.019) and tumor diameter (p=0.016) were significantly related to the patients who showed aggravation of global QOL after brain tumor surgery. In the aggravated global QOL group, common complaints and concerns included role function, appetite loss, financial difficulty and future uncertainty.

Conclusion

In brain tumor patients, HRQOL has improved after surgery. Role function, appetite loss, financial difficulty and future uncertainty were important factors for HRQOL in brain tumor patients treated with surgery. Although there is National Health Insurance and Medical Aid program in Korea, financial difficulty and future uncertainty are much more important in influencing QOL than previously thought. The results of this short-term follow up preliminary study suggest that several factors were related to HRQOL, Further research is needed to evaluate the long term change of HRQOL and enhance the global QOL by analyze related factors.

Assessing cancer patients' quality of life and supportive care needs: Translation-revalidation of the CARES in Flemish and exhaustive evaluation of concurrent validity

BACKGROUND

The prevalence of cancer increases every year, leading to a growing population of patients and survivors in need for care. To achieve good quality care, a patient-centered approach is essential. Correct and timely detection of needs throughout the different stages of the care trajectory is crucial and can be supported by the use of screening and assessment in a stepped-care approach. The Cancer Rehabilitation Evaluation System (CARES) is a valuable and comprehensive quality of life and needs assessment instrument. For use in Flemish research and clinical practice, the CARES tool was translated for the Dutch-speaking part of Belgium (Flanders) from its original English format. This protocol paper describes the translation and revalidation of this Flemish CARES version.

METHODS

After forward-backward translation of the CARES into Flemish we aim to recruit 150 adult cancer patients with a primary cancer diagnosis (stage I, II or III) for validation. In this study with a combination of qualitative and a quantitative approach, qualitative data will be collected through focus groups and supplemented by two phases of quantitative data collection: i) an initial patient survey containing questions on socio-demographic and medical data, the CARES and seven concurrent instruments; and ii) a second survey administered after 1 week containing the CARES and supplementary questions to explore their impressions on the content and the feasibility of the CARES.

DISCUSSION

With this extensive data collection process, psychometric validity of the Flemish CARES can be tested thoroughly using classical test theory. Internal consistency of summary scales, test-retest reliability, content validity, construct validity, concurrent validity and feasibility of the instrument will be examined. If the Flemish CARES version is found reliable, valid and feasible, it will be used in future research and clinical practice. Comprehensive assessment with the CARES in a stepped-care approach can facilitate timely identification of cancer patients' psychosocial concerns and care needs so it can contribute to efficient provision of patient-centered quality care.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02282696 (July 16, 2014).

Associations among physical activity, comorbidity, functional capacity, peripheral muscle strength and depression in breast cancer survivors

Physical inactivity may an important outcome in the prognosis of breast cancer. Physical activity levels decrease significantly for breast cancer patients following the treatment and remain low after oncology treatment is completed. The aim of this study was to determine physical activity levels and to examine associations among physical activity, comorbidity, functional capacity, peripheral muscle strength, and psychosocial status in breast cancer patients. Forty breast cancer survivors were included in this study. Demographic and clinical characteristics were recorded. Physical activity was assessed with a short form of the International Physical Activity Questionnaire (IPAQ). We defined comorbid diseases according to the Charlson Comorbidity Index (CCI). Functional capacity was evaluated with a six-minute walk test (6MWT). Peripheral muscle strength was measured for quadriceps femoris muscle with a hand-held dynamometer. Psychosocial status was measured with the Hospital Anxiety Depression Scale (HADS). Forty percent of patients were inactive. The IPAQ total score was significantly related with quadriceps muscle strength (r=0.492; p<0.001) and HADS depression score (r=0.341; p<0.05). Marked correlations were also observed between IPAQ walking score and quadriceps muscle strength (r=0.449; p<0.001), HADS depression score (r=0.341; p<0.05), and CCI (r=-0.433; p<0.001). The CCI score was also markedly associated with quadriceps muscle strength (r=-0.413; p<0.001). 6MWT distance was not significantly correlated with any of the parameters. Regression analyses revealed that psychosocial status and peripheral muscle strength were significant predictors of physical activity estimated with the IPAQ short form and when combined, they explained 35% of the variance. Comorbidities, peripheral muscle strength and psychosocial status partially explain the variability of physical activity level in breast cancer survivors. These results suggest that physical inactivity contributes to worsening health in breast cancer survivors.

Multidisciplinary rehabilitation after primary brain tumour treatment

BACKGROUND

Brain tumours can cause significant disability, which may be amenable to multidisciplinary rehabilitation. However, the evidence base for this is unclear. This review is an update of a previously published review in the Cochrane Database of Systematic Reviews [2013, Issue 1, Art. No. CD009509] on 'Multidisciplinary rehabilitation after primary brain tumour treatment'.

OBJECTIVES

To assess the effectiveness of multidisciplinary rehabilitation in people after primary brain tumour treatment, especially the types of approaches that are effective (settings, intensity).

SEARCH METHODS

For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL, the Cochrane Library up to Issue 12 of 12, 2014), MEDLINE (1950 to January week 2, 2015), EMBASE (1980 to January week 2, 2015), PEDro (1985 to January week 2 2015), and LILACS (1982 to January week 2, 2015). We checked the bibliographies of papers we identified and contacted the authors and known experts in the field to seek published and unpublished trials.

SELECTION CRITERIA

Controlled clinical trials (randomised and non-randomised clinical trials) that compared multidisciplinary rehabilitation in primary brain tumour with either routinely available local services or lower levels of intervention, or studies that compared multidisciplinary rehabilitation in different settings or at different levels of intensity.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed study quality, extracted data, and performed a 'best evidence ' synthesis based on methodological quality.

MAIN RESULTS

We did not identify any studies for inclusion in the previous version of this review. For this update, the literature search identified one low-quality controlled clinical trial involving 106 participants. The findings from this study suggest 'low-level' evidence to support high-intensity ambulatory (outpatient) multidisciplinary rehabilitation in reducing short- and long-term motor disability (continence, mobility and locomotion, cognition), when compared with standard outpatient care. We found improvement in some domains of disability (continence, communication) and psychosocial gains were maintained at six months follow-up. We found no evidence for improvement in overall participation (quality of life and societal relationship). No adverse events were reported as a result of multidisciplinary rehabilitation. We found no evidence for improvement in quality of life or cost-effectiveness of rehabilitation. It was also not possible to suggest best 'dose' of therapy.

AUTHORS' CONCLUSIONS

Since the last version of this review, one new study has been identified for inclusion. The best evidence to date comes from this CCT, which provides low quality evidence that higher intensity ambulatory (outpatient) multidisciplinary rehabilitation reduces short- and long-term disability in people with brain tumour compared with standard outpatient care. Our conclusions are tentative at best, given gaps in current research in this area. Although the strength of evidence has increased with the identification of a new controlled clinical trial in this updated review, further research is needed into appropriate and robust study designs; outcome measurement; caregiver needs; evaluation of optimal settings; type, intensity, duration of therapy; and cost-effectiveness of multidisciplinary rehabilitation in the brain tumour population.

Clinical implications of motor deficits related to brain tumors†

Motor deficits, including unilateral or bilateral weakness, plegia, ataxia, spasticity, and loss of complex movement execution, can occur during any brain tumor illness. Tumor location, treatment effects, and medications contribute to these deficits. Motor dysfunction has been associated with significant deterioration in health-related quality of life in patients with primary and metastatic brain tumors. Significant decrease in median overall survival has been reported in patients with motor deficits, although the reasons for this are unclear. Motor deficits, particularly gait impairment, contribute to significant symptom burden at end of life, and are the most common reasons for initiation of hospice care. Interventions must focus on prevention and amelioration of motor dysfunction throughout the disease course in order to preserve quality of life. The impact of exercise in prolonging survival and improving quality of life requires further study.

Effect of cosmetic outcome on quality of life after breast cancer surgery

PURPOSE

Studies regarding the effects of aesthetic outcomes after breast cancer surgery on quality of life (QoL) have yielded inconsistent results. This study analyzed the aesthetic outcomes and QoL of women who underwent breast conserving surgery (BCS) or total mastectomy with immediate reconstruction (TMIR) using objective and validated methods.

PATIENTS AND METHODS

QoL questionnaires (EORTC QLQ-C30, BR23, and HADs) were administered at least 1 year after surgery and adjuvant therapy to 485 patients who underwent BCS, 46 who underwent TMIR, and 87 who underwent total mastectomy (TM) without reconstruction. Aesthetic results were evaluated using BCCT.core software and by a panel of physicians. Patients' body image perception was assessed using the body image scale (BIS).

RESULTS

QoL outcomes, including for social and role functioning, fatigue, pain, body image, and arm symptoms, were significantly better in the BCS and TMIR groups than in the TM group (p<0.05 each). BIS was significantly better in the BCS than in the TM or TMIR group (p<0.001 each). In the BCS and TMIR groups, general QoL factors were not significantly associated with objective cosmetic outcomes, except for body image in the QLQ-BR23. In contrast, patients with poorer BIS score reported lower QoL in almost all items of the QLQ-C30, BR23, and HADS (p<0.05 each).

CONCLUSION

In conclusion, BCS and TMIR enhanced QoL compared with TM. Among BCS and TMIR patients, objectively measured cosmetic results did not affect general QoL. Self-perception of body image seems to be more important for QoL after breast cancer surgery.

The effect of an interdisciplinary rehabilitation intervention comparing HRQoL, symptom burden and physical function among patients with primary glioma: an RCT study protocol

INTRODUCTION

Gliomas are among the biggest challenges in neurological and oncology rehabilitation and optimising treatment is of major clinical importance in this population. Although inpatient rehabilitation among glioma patients' results in improved functional measures, rehabilitation efforts are still not emphasised in this patient group and the literature lacks studies investigating the impact of outpatient rehabilitation.

METHOD

This protocol describes a randomised 6-week parallel group rehabilitation study investigating an outpatient interdisciplinary rehabilitation programme. The intervention consists of 6 weeks intensive physiotherapy as groups exercise in conjunction with 0-6 weeks of individual occupational therapy if a need is present. The aim of this study is to describe the design of the upcoming randomised control trial (RCT). The results of the RCT will add to the growing body of literature investigating the potential role of exercise as a supportive therapeutic intervention for a patient with cancer.

ETHICS AND DISSEMINATION

The project is approved by the Regional Scientific Ethical Committees for Southern Denmark under Project-ID: (S-20140108) and by the Danish Data Protection Agency (J. no.2008-58-0035). Dissemination will occur through presentation and findings will be published in peer-reviewed journals. The key strength of this study is its randomised design and it is the first study to investigate a standardised outpatient interdisciplinary rehabilitation programme among patients with glioma. A potential limitation is the uncertainty and risk of side effects to the concomitant treatment, which enhances the risk of dropout.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier NCT02221986.

Weight of epilepsy in brain tumor patients

About 20-40% of patients with brain tumor have seizures; all of whom must be treated with antiepileptic drugs (AEDs) that can cause side effects which may influence quality of life (QoL). However, little data are available regarding the weight of epilepsy on QoL in brain tumor (BT) patients, despite the fact that epilepsy is considered the most important risk factor for long-term disability in this patient population. Aim of this study is to explore the weight of epilepsy in BT patients, and to identify which factors might contribute to their epilepsy burden, as expressed by them only at their first visit in a specialized epilepsy center, in order to have a snapshot for that moment in their care cycle. We reviewed medical charts and results from a battery of tests (routinely given at our outpatient center), administered to 100 consecutive BTRE patients at their first visit, followed from 2007 to 2010. Our results reveal: (1) neurological performances and global neurocognitive status were not influenced by factors related to neoplastic disease or to epilepsy (2) side effects, cognitive deficits, and QoL concerns, as well as patients' perception of these, were significantly related to polytherapy, especially in patients who had been taking AEDs for a period longer that 6 months (3) the seizure number did not influence patients' QoL. We found that the weight of epilepsy in BTRE patients was related to AED therapy. Our study highlights the fact that epilepsy in our patients adds a significant burden, and suggests the need to give the proper attention to patients' concerns regarding the challenges that this pathology might present. Nevertheless, future studies could be designed with a follow-up period and with a patient stratification in order to better understand the weight of epilepsy for these patients.

Depressed mood in breast cancer survivors: associations with physical activity, cancer-related fatigue, quality of life, and fitness level

PURPOSE

One out of five cancer survivors suffer from depression after oncology treatment. The aim of this study was to examine the relationship between depression and quality of life (QoL), cancer-related symptoms, physical activity level, health-related fitness, and salivary flow rate in breast cancer survivors.

METHOD

108 breast cancer survivors in the year after the conclusion of treatment were included in this cross-sectional study. Demographic and clinically relevant information, cancer-related fatigue (Piper Fatigue Scale), QoL (QLQ-Br23 module), pain intensity VAS scale, salivary flow rate, physical activity level (Minnesota Leisure Time Physical Activity Questionnaire), and health-related fitness were assessed in all participants. Depressed mood was measured with the Profile of Mood States (POMS) Depression subscale.

RESULTS

Significant positive correlations between depressed mood and fatigue, systemic side effects, perceived shoulder pain, and breast-arms symptoms (r ranged between .57 and .28, P < .01) were found. In addition, significant negative correlations between depressed mood and body image, future perspective, force handgrip, and physical activity level (r ranged between -.41 and -.19; p < .05) were found. Regression analyses revealed that cancer-related fatigue, physical activity level, systemic side effects, and body image were significant predictors of depressed mood, and when combined, they explained 39.6% of the variance in depressed mood.

CONCLUSIONS

Cancer-related fatigue, physical activity level, and QoL partially explain the variability of depressed mood in breast cancer survivors. This paper facilitates a better understanding of the relationship between depressed mood and possible factors associated with it.

Impairment-driven cancer rehabilitation: an essential component of quality care and survivorship

Adult cancer survivors suffer an extremely diverse and complex set of impairments, affecting virtually every organ system. Both physical and psychological impairments may contribute to a decreased health-related quality of life and should be identified throughout the care continuum. Recent evidence suggests that more cancer survivors have a reduced health-related quality of life as a result of physical impairments than due to psychological ones. Research has also demonstrated that the majority of cancer survivors will have significant impairments and that these often go undetected and/or untreated, and consequently may result in disability. Furthermore, physical disability is a leading cause of distress in this population. The scientific literature has shown that rehabilitation improves pain, function, and quality of life in cancer survivors. In fact, rehabilitation efforts can ameliorate physical (including cognitive) impairments at every stage along the course of treatment. This includes prehabilitation before cancer treatment commences and multimodal interdisciplinary rehabilitation during and after acute cancer treatment. Rehabilitation appears to be cost-effective and may reduce both direct and indirect health care costs, thereby reducing the enormous financial burden of cancer. Therefore, it is critical that survivors are screened for both psychological and physical impairments and then referred appropriately to trained rehabilitation health care professionals. This review suggests an impairment-driven cancer rehabilitation model that includes screening and treating impairments all along the care continuum in order to minimize disability and maximize quality of life.